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Body Dysmorphic Disorder (BDD)

BDD usually starts in adolescence or early adulthood, and is a morbid
intensification of the normal minor worries about the body, which are common
at that age. Technically, BDD is a preoccupation with a nonexistent or minimal
defect in appearance that generates significant distress or impairment in
social, occupational and/or other important areas of life; and involves unrealistic
beliefs in other people’s reactions to this ‘ugliness’.

People with BDD put a very large emphasis on their appearance and believe
that other people evaluate them negatively solely on the basis of this appearance.
Whether this is as shallow as in: ‘pretty people equals nice people’,
or has a darker side where becoming the subject of attention raises social
fears or the perception that the ‘deformity’ is a visual signal
to prove internal badness, will be to do with the individual. Research suggests
that 29% of people with BDD have other obsessions and compulsions completely
separate from their BDD handicap and that BDD might even be classed as a
more severe form of OCD. BDD should not be confused with vanity or ‘normal’
concern with one’s looks and appearance. It is also sometimes confused
with Social Anxiety Disorder and research does suggest that BDD sufferers
tend to be shy. Unlike people with Social Anxiety problems, the BDD sufferer
does not tend to find the problem ‘silly’ and will be just as
anxious when alone as when in company. He or she is also likely to become
upset when the perceived ‘ugliness’ is mentioned.

‘Normal concern with one’s appearance’ is, of course,
a subjective term. Over the past few decades’, the acceptability of
concern about appearance has grown in Western cultures alongside the availability
of clothing and cosmetics to achieve changes and improvements and the financial
resources to purchase these.

At different times and at different ages we may all have an increase in
our perceived need to ‘look perfect’ and many people have an
ongoing dissatisfaction with their appearance that might stray into the regions
of BDD on occasion. However, people with BDD will be spending at least
an hour a day (and often very much more) checking in front of mirrors and
other reflective surfaces (or avoiding these at all costs; or doing either
at various times), camouflaging the perceived defect with excessive use of
cosmetics, or inappropriate clothing such as scarves hats and sunglasses
(inappropriate to the specific situation that is), avoiding social contact
and suffering much internal torment and despair.

‘BDD preoccupations have been noted to structurally resemble
obsessions in that they are distressing and anxiety producing, persistent
recurrent thoughts that are difficult to resist or control.’
(Phillips et al. ’95)

Looking at the literature, it is difficult to gauge where a preoccupation
enters the world of obsession and then, sometimes, delusion. All levels
of obsessional thinking have a tendency in that direction. Many people
have come to Anxiety Care with ‘absolute’ beliefs in certain
things: the requirement to be perfect with only total loss of personal value
as an alternative; a belief that a certain activity has caused irreparable
harm despite endless proof to the contrary; a belief that only evil people
have negative thoughts. It goes on and on.

As delusions are fairly common in the general population, (one research
project showed that nearly 10% of ‘healthy’ people had more delusional
beliefs than the average score from someone with severe psychotic illness),
it seems fair to conjecture that they are not an all-or-nothing concept;
that they exist on a continuum of insight (how far we are able to judge their
validity) that ranges from good through poor to absent altogether.

This might ease the minds of some people who visualise their disorder
plunging them into psychosis that, to most, is synonymous with raving madness.
A further comfort should be that BDD does not respond to anti-psychotic medication,
but does to the SRI’s, which are the medications of choice for OC disorders.

The whole area of: ‘My BDD, is it or isn’t it delusional?’
is probably not worth too much attention unless a sufferer allows such feelings
to take them into extreme remedies such as ‘self-surgery’ (picking
or trying to cut out a perceived blemish), total withdrawal or acute depression.
Research seems to suggest that higher doses of one or other SRI would be
indicated in these situations.

Research further suggests that surgery is rarely useful. People with psychologically
untreated BDD might then simply transfer to another bodily ‘abnormality’
or focus more on the surgically altered one, seeing it as still ugly and
still in need of attention. There is anecdotal evidence that people
who have surgery tend to gain little long term benefit because it is a symptom
being treated, not the problem. In such cases, it would not be unusual
to hear the person concerned, once the euphoria of having surgery has worn
off saying that his/her life will be perfect once the nose/mouth/eyes etc
have been really put right. Without adequate treatment of the BDD this ‘really’
might only stop when the money runs out or when surgeons refused to operate
any more.

Like OC problems in general, reassurance or practical alterations to the
situation; in the case of BDD, activity that colludes with the perceived
need to hide the ‘deformity’, are very unlikely to work. The
combination of cognitive behavioural therapy involving exposure and response
prevention, plus medication is the treatment of choice.

There are differences between OC thinking and BDD thinking. The BDD thinker
may view the thoughts as relevant to his or her personality and beliefs;
and, although severe and debilitating, a ‘normalish’ part of
life. The OC thinker on the other hand will invariably view the thoughts
as intrusive and alien, nothing to do with his or her perceived once ‘true’
personality.

The OC thinker will also use ‘curing’ thoughts such as counting,
thinking ‘good things’ etc. that are relevant to him or her but
probably have little connection with the intrusive thought or thoughts that
they are used to counter. The BDD thinker will invariably be focused
on the perceived abnormality and all thoughts will surround this area and
be totally relevant (to the sufferer at least) to the cause of preventing
the abnormality being seen.

Then, although the BDD sufferer might indeed have ‘classic’
OC symptoms as well, the situation once encountered in a group can be understood.
This was during a discussion about thought processes. Two people presenting
with OC problems around thinking had both been asked to write down their
thoughts by a therapist. The one whose thought processes were perceived
as alien to his true character, had been horrified at the way one thought
led to another. That is, when writing the thoughts down and the inevitable
happened: ‘The therapist is going to read this, I’d better not
think anything worse, like…oops!’ This person was appalled at
his ‘evil’ and completely missed the fact that a worsening of
thoughts and images was unavoidable once a process aimed at not-thinking
worse things had been slotted into place.

The BDD sufferer, on the other hand, quickly understood the situation
and stopped writing the thoughts down when it became obvious to her that
it was the fact that these thoughts were going to be read that was making
them more and more alien and embarrassing, not the content of her character.
A discussion then began about how this situation could have occurred, so
different between two people with the perceived same problem. The answer
was, of course, that they did not have the same thinking problem. The
OC thinker was locked into ‘bad’ thoughts as a sign of
personal evil and so was super sensitive too, and invariably subject too,
a series of such thoughts that, in reality, had no end.

The BDD thinker was only sensitive to thoughts that revolved around her
‘deformity’. She was capable of processing some ‘evil’
thoughts as a sign of low personal value and inadequacy as a wife and mother,
but beyond a certain point had rational beliefs in her character. In
short, she saw herself as worthless in many ways, but not evil or potentially
out of control, while the OC thinker saw himself as basically worthy but
becoming progressively more evil and coming closer to the point where he
would lose control.

‘Non-psychological therapy in people with BDD
may do more harm than good.’
(bpinsky3)

Another difference between OC and BDD thinking is that the OC thinkers
‘curing’ thoughts and rituals are used to reduce anxiety, while
the BDD thinker’s thoughts are not used in that way at all. The
BDD thinker will be hyper vigilant with thoughts focused entirely on concerns
about the abnormality. These thoughts will, like the OC, be maintaining the
disorder but in a different way. The OC’s relief by ‘curing’
a bad thought with another keeps the disorder active, while the BDD thinker
does not cure the thoughts internally, but uses physical camouflage to hide
the manifestation of the fear, which only maintains focus on the abnormality,
the thoughts about it, and the anxiety that goes with the whole process.

One researcher presents a series of ‘clues’ to the presence
of BDD that, while not required as part of a diagnosis, might be useful for
anyone concerned that he or she or a family member has this disorder.
Below is a slightly abridged version:

Frequently comparing your appearance with that of others; scrutinizing
the appearance of others

Often checking your appearance in mirrors and other reflecting surfaces

Avoiding social situations in which the perceived defect might be exposed

Feeling very anxious and self-conscious around other people because
of the perceived defect

‘BDD usually begins during early adolescence, although it can
occur in children and can also begin in adulthood. It appears to be
a waxing and waning disorder this is generally chronic. Other disorders
can co-exist with BDD and may be more obvious to…a casual observer
than BDD itself, which may be hidden. These disorders include depression,
social phobia, and obsessive/compulsive disorder, which may be closely related
to BDD.’
(Albertini and Phillips)

A questionnaire that originated from worldcollegehealth.org suggested that BDD is a possibility if ‘yes’
is the answer to the following questions:

Are you very worried about the way you look?

If ‘yes’, do you think about your appearance problems a
lot and wish you could think about them less?
(Examples of disliked body area include: your skin, [e.g., acne, scars, wrinkles,
paleness, redness]; hair; the shape or size of your nose, mouth, jaw, stomach,
hips etc.; or defects of your hands, genitals, breasts or any other body
part.)

Has this problem often upset you a lot?

Has it often got in the way of social activities?

Do you spend more than an hour each day thinking about how you look?

Research indicates that it can take as long as three months (or occasionally
longer) for the SRI medication to work, as is true with all SRI medications,
and that relatively high doses may be needed for BDD; and that improvement
of symptoms may be gradual so patience is essential.

From Anxiety Care’s experience it is vital to talk to the prescribing
physician, when taking medication, if any side effects problems occur (and
they will happen, if they are going to, before the benefit is felt) as many
people, not totally convinced that medication is the answer, use temporarily
unpleasant side effects as an excuse to abandon medication.

Cognitive behavioural treatment is sometimes useful but will only be truly
effective if the sufferer understands that his or her perception of the defect
is exaggerated.

‘Supportive psychotherapy serves to create a positive environment
in which to apply other therapeutic techniques, but doesn’t seem to
work by itself. Other psychotherapeutic approaches (for example, insight-oriented
psychotherapy, diet and natural remedies) have not been shown to be effective
for BDD.’
(Albertini and Phillips)

OLFACTORY OBSESSIONS

Another problem may fit in among the OC Spectrum disorders, possibly close
to BDD: olfactory obsessions. This involves the sufferer believing
that some part of his or her body is producing an unpleasant and noticeable
odour. Anxiety Care has encountered this problem in a number of younger people
and adolescents.

There is research that suggests that, for the olfactory obsessive,
the level of anxiety generated by social situations and the tendency to assume
judgments of ones value as a person will be made by outsiders around the
‘fact’ of this smell, make it very close to BDD. Intense anxiety,
hyper vigilance, shame and the need for reassurance are all similar to BDD
with more similarities to this disorder than to classical OCD.

The treatment approach is much the same as for BDD. Sufferers must
be helped to understand that their bodies will, occasionally, produce odours,
just like everyone else’s, but that this is not a sign that the belief
was true and that eternal vigilance should be maintained. Sufferers
have to be helped to accept the disorder as a disorder, and to live with
the possibility that the problem exists – nobody will guarantee them
permanently freedom from bodily odour.

As mentioned earlier, our current culture puts much emphasis on looking
good and this includes smelling good, so a minor level of olfactory worry
may not be unusual. A recent episode of a popular television series
featured a character, after being prevented from bathing for a modest period,
stating that she smelt and that she hadn’t been aware that her body
was capable of producing such an odour. This was obviously played for humour
but was the more funny for portraying an almost-believable attitude in a
certain type of person.

So olfactory obsession is, again, something that most of us might mistakenly
believe we can relate too – we don’t like to smell. However
this will be to an olfactory obsession as the proverbial tension headache
is to a skull splitting migraine. People at the tension headache end of the
continuum do not ruminate endlessly about the problem or spend much time
trying avoiding social contact or watching surrounding activity (wrinkled
noses, opening windows, ‘odd’ looks) for proof that the obsession
is a reality.

Olfactory obsessives will probably need to be helped to take practical
steps such as reducing bathing, reducing excessive use of deodorants and
gradually getting used to the idea that they can tolerate the possibility
that they have an odour and that this is not the end of life as they know
it. And, as always, the mark of recovery is not the extinguishing of
the belief, but the perception that it doesn’t matter one way or another.

Like all obsessional thinking problems, the need for a 100% guarantee
of immunity from fear is not the target, relief comes from accepting the
response at whatever level it settles down to (maybe, with olfactory problems,
you will always be a bit more concerned than most about your body odour)
and understanding that this is just life and doesn’t stop it being
liveable unless you choose to make it so.

SOME TREATMENT SUGGESTIONS

As mentioned, BDD sufferers may respond to one or other of the SRI (Serotonin
Re-uptake Inhibitor) anti-depressant medications, which often work well on
mixed anxiety, obsession and depression. Exposure treatment can work
too, especially in overcoming social aspects of the problem (see the leaflet
on social phobia).

A standard exposure programme of the type used in behavioural therapy
cannot be offered here for all BDD problems of course; but, for example,
someone who wears excessive makeup might be gently persuaded or helped to
gradually reduce the amount used over a period of weeks by a small further
reduction every day. Starting with what she can just about tolerate and working
up in gentle steps; cutting some steps done into mini-steps if they present
a problem. As said in other literature, there are no prizes for getting
better the most difficult or painful way

A person who spends many hours a day looking in mirrors (see Rachel’s
story below) could be helped to reduce these periods by a small amount every
day using, for example, a kitchen timer to take, for example, two or three
minutes off every subsequent visit to the mirror. This technique might
also be used where the person spends long periods of time putting on makeup
in front of a mirror every day. If, as mentioned, the BDD sufferer alternates
between excessive mirror gazing and avoiding them at all costs, the presence
of a small mirror in a room could be negotiated and the sufferer could them
be helped to pass close to it and then tolerate looking into it for gradually
lengthening periods. Suddenly producing a mirror in front of a BDD sufferer
with this aspect to the problem is not a good idea. It is likely to
make him or her lose trust in the person doing it and anyone helping a sufferer
with an exposure programme has to be totally trustworthy.

Where odd or excessive clothing is concerned, the person might be encouraged
to wear less – indoors at first, then on short outings in very familiar
surroundings; working up to longer and longer journeys and more and more
practical clothing. It should be borne in mind however, that where excessive
and odd clothing is used, reducing one might not automatically make it easier
to reduce the other. So the person might be at different recovery points
with the different problems. For example, able to go out in clothing
more suitable for the season, but still wearing too much of it. This
might seem odd to outsiders, but nobody observing or helping a BDD sufferer
should try to apply his or her own personal logic to the problem. The family
and the helper, if there is one, are working with the sufferer’s reality,
not the other way around.

Journeys out might also require the support of a trusted friend at first.
Here, the friend would accompany the sufferer on each journey, ready to chat
or distract the person if problems are foreseen (but not too much). The friend
might then walk a little apart from the BDD sufferer as confidence grows;
then further and further apart.

The friend must treat these tasks very seriously if they are undertaken.
He or she must concentrate on the subject, no wandering off or looking in
shop windows. A balance has to be attained where the friend does not
show over concern that might trigger anxiety in the subject, but is attentive
enough to note possible problems ahead such as shop windows (reflections),
or large numbers of people (particularly children who might make fun of somebody
wearing excessive makeup or odd clothing). If the sufferer is in the habit
of seeking a great deal of reassurance from the friend or family before and
during exposure tasks such as this, or during normal activity, families and
friends can be helped to learn to refuse this. Reassurance does not relieve
the condition but, in the long term, strengthens the anxiety as it works
against the sufferer using his or her own strength and determination to endure
the physical and/or mental feelings engendered by the anxiety.

To deal with excessive reassurance seeking, families (or friends) might
practise with the sufferer (on a good day) saying something like: “We
agreed that I would not give you reassurance”; or they might negotiate
with the sufferer over very serious difficulties by agreeing to reassure
once only. It is important that this scenario is an agreed one and that the
sufferer is not bullied into accepting less reassurance. Trust is an important
part of recovery when families are involved with it. The person with BDD
will almost certainly already have low self-esteem and be concerned over
upsetting family members. He or she might well reduce reassurance seeking
for a while if bullied or shouted at, but this will be for personal reasons
and have nothing to do with recovery.

Exposure work should be undertaken for an hour or so every day.
It should also be noted that large amounts of anxiety are no better than
small amounts when trying exposure work. In fact, large amounts might
actually work against the sufferer trying again; for who wants to spend a
great deal of their time very frightened?

It is also useful for the sufferer to keep a journal, noting down every
exposure activity and the level of anxiety experienced each time, where 10
is as high as can be imagined and 0 is none at all. So, for example, minor
anxiety might be noted as 2 or 3 and medium, 4 or 5 etc. Most people quickly
become expert at recording their anxiety levels accurately. This helps because
a person undertaking an exposure programme sometimes misinterprets improvements
or manages to persuade him- or herself that something attained is not an
improvement at all. Looking back over a journal that details feelings and
fears and how they were perceived at the time, counters this.

However, it must be borne in mind that (in general) people with BDD tend
not to believe that their fears are unfounded, and thus they may not be willing
to undertake exposure work – at this point anyway. When they
do agree to do so, it can be a slow business.

If there is a very minor blemish that has grown in the person’s
mind to dysmorphic proportions and this is the only area in which the sufferer
has problems (that is, he or she does not have a range of body parts that
cause anxiety), referral to a plastic surgeon might, just might, be the answer;
but a more appropriate referral in most cases would be to a clinical psychologist
or psychiatrist who understands this condition. As said earlier, someone
who has totally unrealistic concerns about a body part, or many areas of
the body which cause anxiety, would almost certainly not be aided by one
surgical response; and once started it might be difficult to stop.

RACHEL’S STORY

Rachel, a married woman with two teenage children, has had BDD problems
with her eyes since her teens. She recalls once being teased badly
over the shape of her eyes at school and remembers the problem growing from
there.

She began to worry about their shape and how red they seemed to look at
times (she had a tendency to skin irritation in that area which added to
the problem), feeling that people would notice this and find her strange
and unattractive. This was not vanity or a desire to be extremely sexually
attractive, but a belief that people might be able to detect how bad she
felt about herself.

She would spend great lengths of time looking in mirrors, scrutinising
her eyes. This occurred at home, at her place of work and in any outside
environment where mirrors were available.

At one point, she had noted the existence of every mirror and mirrored
surface available on her normal daily travels and looked at them all, taking
very long periods of time to complete the simplest of outdoor activities.

In desperation, her family locked away all the mirrors in the house.
However, she then began to look at her eyes in other surfaces such as knife
blades, spoons, even the washing up water; and she would seek out mirrors
when the anxiety was very high, finding where her husband had hidden his
shaving mirror and using this.

She was in the habit of seeking reassurance from her husband that her
eyes didn’t look strange or red. When he became upset by this and refused
to continue, she then sought the same help from her young children; This
made her feel as if she was abusing them and added to her anxiety and feelings
of low self worth.

Even when she was aware that the ‘reassurance’ the family
was giving was annoying them and that they were giving it without really
looking at her, she still continued until shame and humiliation made her
stop each time.

She determined to make it up to her family by becoming the best mother
she possibly could in other areas. This lead to a great deal of extra
work, then extreme tiredness and more anxiety.

Rachel had to give up her job because of the anxiety and depression generated
by the problem, but this did not ease the BDD. Every day was a nightmare.
She felt compelled to look in mirrors for long periods, but also tried to
avoid them, knowing how long and how anxiety generating the process would
be if she ‘succumbed’ when away from the house, regularly having
to convince herself that a chance reflection in some surface did not require
her to linger for long periods looking at herself. Sometimes she felt
that she was humiliating herself in front of people by doing this, but often
the anxiety was so high that she did not care.

In this way, Rachel spent many years of her life. She undertook
several types of psychotherapy both as an inpatient and as an outpatient,
but nothing really worked. Eventually she joined an Anxiety Care support
group. Over a period of two years, she began to rebuild her confidence
through group discussion and one-to-one counselling.

Eventually she took on small responsibilities and began
to work at helping other people, many of them with obsessive/compulsive disorder
(OCD). Though none of them had a BDD condition, many of the obsessive
and compulsive activities described by these people were very similar to
her own problems.

Rachel is showing steady improvement.
She has had a number of quite severe ‘normal’ problems in her
life over the past year or two but has dealt with them well: they did not
push her back into BDD habits, which is a good sign that major changes in
perception and improvements in self-value have been attained.